Please list at least four persons who can vouch for your reputation, character, and morals. Please do not use relatives, spouse, or significant other.

They MUST have known you for at least one year.

One reference MUST be a work or school reference

One reference should be familiar with your home enviroment

All information will be treated confidentially and will not be shared.

Reference One

Name:
Address:
City:
State:
Zip Code:
Phone:
E-Mail:

Reference Two

Name:
Address:
City:
State:
Zip Code:
Phone:
E-Mail:

Reference Three

Name:
Address:
City:
State:
Zip Code:
Phone:
E-Mail:

Reference Four

Name:
Address:
City:
State:
Zip Code:
Phone:
E-Mail:

Legal Record

Arrest/Violation Date: / / (MM/DD/YYYY)
Charge:
Disposition/Result:

Arrest/Violation Date: / / (MM/DD/YYYY)
Charge:
Disposition/Result:

Statement of Understanding

If I am accepted as a Big Brother/Big Sister, I understand my obligation to meet with my Little
Brother/Sister regularly and to inform BBBS agency staff as to the status of my match relationship every
month. I further agree to accept the supervision of the BBBS staff and discontinue my service if I am
requested to do so by the agency.